“The trouble starts when I fail to notice that I see only whatever confirms my categories and expectations but nothing else. The trouble deepens even further if I kid myself that seeing is believing. That’s wrong. It’s the other way around. You see what you expect to see.”
Karl Weick & Kathleen Sutcliffe
Managing the Unexpected
Willow Fire Report
The document is the report and findings into the fatal accident of a rapeller at the Willow Creek Helibase in California last year. While it is not "technically" an aviation accident--it was reported as such, and I am sure we can all learn something from the report---especially this piece:
The Human Factors section of the report, beginning on page 33, is particularly interesting. Written by Jim Saveland and Ivan Pupulidy, it discusses, along with other issues, the concept of not seeing elements in our visual field, or “blindness”.
As a side note---the day after the accident, there was a nationwide mandatory stand down and review of equipment and procedures. Some USFS regions chose to extend the stand down, others did not. My crew (Region 4) continued to rappel for the remainder of the season. There is rumor, (I have heard but not seen the document), that there will be no rappelling from Type III helicopters this year.
Here is a brief synopsis of what happened:
Before the rappelling training, Marovich noticed that the Kong clip on his Tri-link was broken. The Kong Clip is used to center the “J” hook at the forward corner of the Tri-link. It is a nice piece of equipment to have, but is not essential. Kong clips are prone to breaking and are not popular. He sought assistance from a spotter trainee who replaced the Kong clip with an “O” ring, which was an authorized substitution.
The “O” ring was installed incorrectly. Before the rappelling attempt, four people looked at or inspected Marovich’s rappelling gear: the spotter trainee who installed the “O” ring, Marovich, and in the helicopter a spotter, and another helitack crewperson who did a “buddy check”.
Marovich fell, unarrested, shortly after stepping out onto the helicopter skid. He was pronounced deceased about 30 minutes later.
Here are some photos from the report showing for illustration purposes examples of a correct and then an incorrect installation of an “O” ring on a Tri-link.
Correct installation:
Incorrect installation:
RIP Tom Marovich